Careen Y. Lowder

Dexamethasone Intravitreal Implant for Noninfectious Intermediate or Posterior Uveitis

OBJECTIVE To evaluate the safety and efficacy of 2 doses of dexamethasone intravitreal implant (DEX implant) for treatment of noninfectious intermediate or posterior uveitis. METHODS In this 26-week trial, eyes with noninfectious intermediate or posterior uveitis were randomized to a single treatment with a 0.7-mg DEX implant (n = 77), 0.35-mg DEX implant (n = 76), or sham procedure (n = 76). MAIN OUTCOME MEASURE The main outcome measure was the proportion of eyes with a vitreous haze score of 0 at week 8. RESULTS The proportion of eyes with a vitreous haze score of 0 at week 8 was 47% with the 0.7-mg DEX implant, 36% with the 0.35-mg DEX implant, and 12% with the sham (P < .001); this benefit persisted through week 26. A gain of 15 or more letters from baseline best-corrected visual acuity was seen in significantly more eyes in the DEX implant groups than the sham group at all study visits. The percentage of eyes with intraocular pressure of 25 mm Hg or more peaked at 7.1% for the 0.7-mg DEX implant, 8.7% for the 0.35-mg DEX implant, and 4.2% for the sham (P > .05 at any visit). The incidence of cataract reported in the phakic eyes was 9 of 62 (15%) with the 0.7-mg DEX implant, 6 of 51 (12%) with the 0.35-mg DEX implant, and 4 of 55 (7%) with the sham (P > .05). CONCLUSIONS In patients with noninfectious intermediate or posterior uveitis, a single DEX implant significantly improved intraocular inflammation and visual acuity persisting for 6 months. Application to Clinical Practice Dexamethasone intravitreal implant may be used safely and effectively for treatment of intermediate and posterior uveitis. Trial Registration clinicaltrials.gov Identifier: NCT00333814.

Low-dose Methotrexate Therapy for Ocular Inflammatory Disease

BACKGROUND Methotrexate is a second-line anti-inflammatory agent used in the treatment of rheumatic diseases. At low doses (12.5 mg/week), it is associated with few serious side effects. METHODS Twenty-two patients (5 men, 17 women) with chronic noninfectious ocular inflammatory disease, who had not responded to or who had become intolerant of corticosteroid or alternate cytotoxic agents, were treated weekly with oral low-dose, pulse methotrexate. Treated diseases included chronic uveitis-vitreitis (9), scleritis (4), inflammatory pseudotumor (3), orbital myositis (3), and retinal vasculitis (3). RESULTS Follow-up ranged from 2 to 39 months (mean, 11 months). Response time ranged from 3 to 9 weeks (mean, 5 weeks) after implementation of methotrexate therapy. Sixteen of 22 patients had reduction of inflammatory activity. Fourteen of these 16 patients were able to taper or discontinue corticosteroid therapy. Five patients had complete remission of their disease; six patients did not respond to methotrexate. CONCLUSION Treatment with low-dose methotrexate appears to be effective therapy for steroid-resistant ocular inflammatory disease.

Phacoemulsification cataract extraction and posterior chamber lens implantation in patients with uveitis

PURPOSE This study reports outcomes of phacoemulsification cataract extraction and posterior chamber intraocular lens implantation within the capsular bag in patients with uveitis. METHODS We retrospectively reviewed the charts of 32 patients (39 eyes) with uveitis who underwent phacoemulsification cataract extraction and posterior chamber intraocular lens implantation by two surgeons at The Cleveland Clinic Foundation from January 1990 to June 1998. Patients with less than 3 months of follow-up were excluded. RESULTS Diagnoses of uveitis included idiopathic (15 eyes), sarcoidosis (10 eyes), pars planitis (four eyes), CMV retinitis (two eyes), Fuchs heterochromic iridocyclitis (two eyes), syphilis (two eyes), and one eye each of tuberculosis, Crohns disease, HLA-B27 associated, and acute retinal necrosis. Average follow-up was 20 months (range, 3 to 63 months). Best-corrected visual acuity improved in 37 eyes (95%). Average improvement was 4 +/- 3 Snellen acuity lines (range, 1 to 10 lines). Thirty-four eyes (87%) attained final visual acuity better than or equal to 20/40. Visual loss occurred in one eye (3%) with CMV retinitis. No improvement in visual acuity was seen in one eye (3%) that developed a retinal pigment epithelial detachment. Posterior capsule opacification occurred in 24 eyes (62%), 12 of which required Nd:YAG capsulotomy (31%). Other postoperative complications included recurrence of uveitis (41%), cystoid macular edema (33%), epiretinal membrane formation (15%), and posterior synechiae (8%). CONCLUSIONS Phacoemulsification cataract extraction with posterior chamber intraocular lens implantation is safe in patients with uveitis. The incidences of recurrence of uveitis, cystoid macular edema, epiretinal membrane, and posterior synechiae were lower than those reported previously for extracapsular cataract extraction.

Clinical features and associated systemic diseases of HLA-B27 uveitis

PURPOSE To delineate the clinical features, course, complications, and associated systemic diseases in patients with HLA-B27-associated uveitis. METHODS We reviewed the records of 148 patients with HLA-B27-associated uveitis from two large uveitis practices. RESULTS There were 127 (86%) white and 21 (14%) nonwhite patients, and a male-to-female ratio of 1.5:1. The median age at onset of uveitis was 32 years; eight patients (5%) had their first attack after age 55 years. Acute anterior uveitis was noted in 129 patients (87%), and nonacute inflammation was noted in 19 (13%). Ocular involvement was categorized as unilateral or unilateral alternating in 138 patients (93%), but ten patients (7%) had bilateral, concurrent disease. The median duration of an attack was six weeks, and the median number of recurrences for patients with more than 12 months of follow-up was three. Cataracts were associated with posterior synechiae (P = .03), increased intraocular pressure (P = .003), and cystoid macular edema (P = .04). An HLA-B27-associated systemic disorder was present in 83 patients (58%), 30 of whom were women, and it was diagnosed in 43 of the 83 patients as a result of the ophthalmologic consultation. Thirty-four (30%) of 112 patients had a family history of a spondyloarthropathy. CONCLUSIONS Although HLA-B27-associated uveitis is usually described as a disease of young white men, women and nonwhites may also be affected. A subgroup of patients have severe disease and consequently more complications. Most patients have an associated systemic disease, including women, who appear to have more atypical spondyloarthropathies. The systemic diseases were frequently undiagnosed before the onset of the ocular disease and before the uveitis consultation.

Extracapsular Cataract Extraction and Posterior Chamber Intraocular Lens Implantation in Uveitis Patients

PURPOSE Intraocular lens implantation in uveitis patients has been a controversial issue. The purpose of this study is to evaluate the visual and surgical outcomes of extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PC IOL) implantation in a diverse group of uveitis patients. PATIENTS AND METHODS The results of 39 cases of ECCE and PC IOL implantation in 30 patients with uveitis were retrospectively analyzed. Five patients (six eyes) had pars plana vitrectomies combined with ECCE and PC IOL implantation. Patient age ranged from 26 to 71 years (average, 53.0 years). Specific uveitic syndromes were determined for 22 patients (73.3%). The postoperative follow-up period ranged from 6 to 43 months (average, 20.3 months). RESULTS Visual acuity improved postoperatively in 38 eyes (97.4%), and this improvement ranged from 1 to 11 Snellen lines (average, 7.5 Snellen lines). Visual acuity improved postoperatively to 20/40 or better in 32 eyes (82%). Seven eyes had visual acuity worse than 20/40, which was attributed to posterior segment abnormalities after ECCE and PC IOL implantation. Uveitis recurred in 20 eyes (51.3%), and postoperative cystoid macular edema (CME) was observed in 18 eyes (46.2%). In all cases, the recurrent uveitis and CME improved or resolved with corticosteroid therapy. CONCLUSION These results suggest selected uveitis patients can have improved vision without unacceptable risk for 1 to 3 years after ECCE and PC IOL implantation.

Posterior segment manifestations of inflammatory bowel disease.

Thirteen patients with inflammatory bowel disease and posterior segment disease were subject to a retrospective review. Eight patients had Crohns disease and five had ulcerative colitis. In six patients, the inflammatory bowel disease was active when ocular inflammation occurred. Patients had one or more posterior segment findings that included serous retinal detachment (8), choroidal infiltrates (6), retrobulbar neuritis (1), papillitis (1), retinal pigment epithelium disturbance (1), and choroidal folds (1). Posterior segment disease responded to systemic and periocular corticosteroids in 9 of 13 cases. Four patients whose disease relapsed after corticosteroid therapy was suspended responded to bowel resection. Ophthalmologists should be aware of the wide spectrum of posterior segment abnormalities associated with inflammatory bowel disease that may require and respond to anti-inflammatory agents.

Glaucoma filtering surgery with postoperative 5-fluorouracil in patients with intraocular inflammatory disease.

Twenty-one eyes of 18 patients with uncontrolled glaucoma and intraocular inflammatory disease had glaucoma filtering surgery with postoperative subconjunctival 5-fluorouracil (5-FU). Follow-up for eyes in which intraocular pressure was controlled ranged from 6 to 53 months (mean, 34 months; median, 35 months). Fifteen of 21 eyes (71%) had controlled intraocular pressure (21 mmHg or less). Control was achieved in 9 of 10 (90%) phakic eyes and in 6 of 11 (55%) aphakic or pseudophakic eyes with or without glaucoma medication. Four of six filter failures had a second filtering procedure with 5-FU, and of these four procedures, three were successful. Cataract progression occurred in 9 of 10 phakic eyes, leading to cataract surgery in 7 eyes. Other complications included corneal epithelial defects in 13 eyes, bleb leaks in 3 eyes, choroidal effusions in 13 eyes, 1 choroidal hemorrhage, 1 serous retinal detachment and macular retinal pigment epithelial disturbance associated with hypotony and choroidal effusion. Filtering surgery with postoperative subconjunctival 5-FU can successfully control intraocular pressure in eyes with ocular inflammatory disease.

Long-term follow-up of extracapsular cataract extraction and posterior chamber intraocular lens implantation in patients with uveitis.

OBJECTIVE The objective of the study was to determine the long-term outcome of patients with uveitis who underwent extracapsular cataract extraction (ECCE) and posterior chamber intraocular lens (PCIOL) implantation. DESIGN Retrospective review. PARTICIPANTS Twenty-eight patients (36 eyes). INTERVENTION Extracapsular cataract extraction and PCIOL implantation. MAIN OUTCOME MEASURES Level of best-corrected Snellen visual acuity, change in visual acuity, length of follow-up, long-term findings, and complications. RESULTS In long-term follow-up (mean, 81.4 months), 94% of eyes had visual acuity improvement compared with preoperative levels. Average change in visual acuity for all eyes was an improvement of 6.4 Snellen lines; 75% of eyes were 20/40 or better. The prevalences of cystoid macular edema (CME), epiretinal membrane (ERM), and posterior capsule opacification (PCO) were 56%, 56%, and 58%, respectively. CONCLUSIONS Patients with uveitis who are treated with ECCE with PCIOL implantation can have successful visual results in long-term follow-up despite the prevalence of PCO or macular abnormalities such as CME and ERM.

Retinal and choroidal vascular occlusion after posterior sub-tenon triamcinolone injection

PURPOSE To report a case of retinal and choroidal vascular occlusion occurring as a complication after posterior sub-Tenon triamcinolone injection for treatment of uveitic cystoid macular edema. DESIGN Interventional case report. METHODS Retrospective study. A 32-year-old woman with uveitis and cystoid macular edema underwent a right posterior sub-Tenon injection of triamcinolone (40 mg/ml, 1 ml total) through a superotemporal approach after topical anesthesia. After the procedure, the patient experienced severe eye pain, orbital ecchymosis, and globe proptosis consistent with retrobulbar hemorrhage. RESULTS Dilated fundus examination of the right eye (OD) demonstrated multiple intraretinal hemorrhages with particulate white emboli occluding the retinal and choroidal vessels. Visual acuity was no light perception. Ocular massage and hypotensive therapy was initiated for an intraocular pressure of 50 mm Hg. Canthotomy and cantholysis were performed. A total of 39 months post-incident, her visual acuity improved to 20/100. CONCLUSION Posterior sub-Tenon triamcinolone injection can rarely result in retinal and choroidal occlusion. Immediate intervention may preserve limited visual acuity.

Surgical management of cataracts in children with juvenile rheumatoid arthritis-associated uveitis

PURPOSE To evaluate outcomes of cataract surgery with posterior chamber intraocular lens (IOL) implantation with or without trabeculectomy in children with juvenile rheumatoid arthritis (JRA)-associated uveitis. DESIGN Interventional case series. METHOD Retrospective chart review of five patients aged 12 years or younger with JRA-associated uveitis who underwent cataract surgery with posterior chamber IOL with or without trabeculectomy at the Cleveland Clinic Foundation from December 1995 to October 2001. RESULTS Four female patients and one male patient ranging from age 7 to 12 years were identified. One patient had bilateral involvement; six eyes were included in the study. Three eyes underwent cataract extraction with posterior chamber IOL, and three underwent combined cataract surgery with posterior chamber IOL and trabeculectomy. Median age at surgery was 8.5 years, with a median follow-up of 43.5 months. Four of five children (five eyes) were on systemic methotrexate immunosuppressive therapy for a median length of 1.25 years before surgery. Two of five patients (three eyes) were also on additional systemic immunosuppressive or anti-inflammatory treatments. All eyes received frequent topical corticosteroid therapy for a median of 2 weeks preoperatively and 8.5 weeks postoperatively. A final postoperative Snellen visual acuity of 20/40 or better was achieved in all children. A median final visual acuity improvement of 7 Snellen lines was observed after cataract surgery. CONCLUSIONS With adequate long-term preoperative and postoperative control of intraocular inflammation with systemic immunosuppressive therapy in addition to intensive topical corticosteroid treatment, children with JRA-associated uveitis can demonstrate favorable surgical outcomes after cataract surgery with posterior chamber IOL.